CARE HOMES FOR OLDER PEOPLE
Gorton Parks Nursing Home 121 Taylor Street Gorton Manchester M18 8DF Lead Inspector
Geraldine Blow Unannounced Inspection 2nd March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Gorton Parks Nursing Home Address 121 Taylor Street Gorton Manchester M18 8DF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 220 9243 0161 230 7439 www.bupa.com BUPA Care Homes (CFHCare) Limited Care Home 148 Category(ies) of Dementia - over 65 years of age (90), Old age, registration, with number not falling within any other category (43), of places Physical disability (15) Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The number of older people requiring nursing care at any one time shall not exceed 43 patients of either sex aged 60 years or over. There are three named service users requiring care by reason of physical disability. Should these service users no longer require the accommodation offered the places will revert to the category of old age (OP). This accommodation is in Sunny Brow and Debdale Houses. In addition a maximum of 12 places are designated for use as intermediate care beds for service users aged 55 and over requiring intensive rehabilitation by reason of physical disability following discharge from hospital care. The rooms are located in Debdale House and equipped with appropriate specialist facilities, equipment and staffing. The length of stay should not normally exceed 6 weeks. A maximum of 60 places in Delamere House and Melland House are registered for older people with dementia who require personal care only. A maximum number of 30 places in Abbey Hey House are registered for either sex aged 60 years or over for people with dementia assessed as requiring nursing care. Minimum nursing staffing levels as specified in the Staffing Notice issued under Section 13 of the Care Standards Act 2000 on 15 February 2006 will be maintained for Sunny Brow and Debdale Houses. The service provider will keep the needs of all service users living in Debdale House under continuing review and ensure that the numbers and skills of staff deployed in that unit are adequate to meet their differing assessed needs. All staff employed in Debdale House will be trained in techniques for rehabilitation as detailed in National Minimum Standard 6.3 (National Minimum Standards, Care Homes for Older People) and this training will be maintained on an ongoing basis. Minimum nursing staffing levels as specified in the Staffing Notice issued under Section 13 of The Care Standards Act 2000 on 15 February 2006, will be maintained in Abbey Hey House. All staff employed in Abbey Hey House must receive accredited training in dementia care by 31st March 2006 and this level of training will be maintained on an ongoing basis. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. 3. 4. 5. 6. 7. 8. 9. 10. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 5 Date of last inspection 7th June 2005 Brief Description of the Service: Gorton Parks Nursing Home is owned by BUPA Care Homes. The home is a purpose built building and consists of 5, 30 bedded units. The home can provide accommodation for 36 residents assessed as requiring nursing care, 60 residents with Dementia assessed as requiring personal care only, 30 residents with Dementia assessed as requiring nursing care and 12 residents 55 years of age and over who require intermediate care. Each unit is a single storey building with a lounge, dining area, a conservatory, a smoke room and a kitchenette. All 150 bedrooms are single and all rooms provide a wash hand basin and a mirror. There are no en-suite facilities available. Accessible toilets and bathrooms, with aids and adaptations for those residents who are wheelchair users or with poor mobility are located near to bedroom and living rooms. The home is located in the residential area of West Gorton in the North of Manchester. Local amenities, including a market, banks and shops are all within easy walking distance. Public transport is accessible. There are ample parking facilities at the front of the building. An administration building houses the main kitchen, hairdressers, laundry and offices. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 2nd March 2006. During the inspection time was spent talking to the deputy manager (head of care), several of the residents and some members of staff to find out their views of the home. In addition residents files, records and other relevant documentation were examined. Since the last inspection the home has completed the registration process and can now offer accommodation for 30 residents with Dementia requiring nursing care and 12 intermediate care beds for residents aged 55 and over. Since the last inspection the registered manager had left the home and a new manager was in post. He took up post in August 2005 and is due to attend an interview with Commission for Social Care Inspection (CSCI) for registration. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. Since the last inspection the CSCI has not received any complaints about the service. However, a concern has been raised by the police department regarding the actions taken by staff during the recent death of a resident. The home has been asked to investigate the concern. What the service does well:
Of the standards assessed during this inspection the home does well in the following areas. Several of the bedrooms had been personalised with photographs, pictures and ornaments that the residents had brought in with them from home. The home has an open visitors policy where people can visit residents at any reasonable time. Residents can see visitors in privacy or in quiet communal areas. No restrictions are placed on visitors unless requested by the resident or otherwise agreed through the care management and risk assessment process. One resident said that “my visitors are made very welcome and you can see them whenever and wherever you want. The deputy manager said that residents are encouraged to make choices and have some control over their day-to-day lives. The staff and residents spoken to confirmed this.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 7 From the systems in place it appeared that the financial interests of residents are safeguarded. What has improved since the last inspection? What they could do better:
A number of concerns were raised regarding the systems and procedures for dealing with medicines. Three bottles of the same medication dated December 2005, January 2005 and February 2005 were found in the drug fridge for the same resident. On further investigation it was found that the medication had been discontinued. In addition there was a great deal of stock medication dating back as far as September 2005. The nurse in charge of the unit could not offer an explanation as to the cause of such a build up. The high stock levels indicate that it is possible that medication may not be being administered correctly. Two bottles of liquid medicine that was currently being administered to a resident had clear instructions on the bottle “do not use after 17/12/05”. A number of prescribed medications had not been signed for. A number of shortfalls were identified in the care planning process. Some of these shortfalls include when a resident had been assessed as at risk of developing a pressure sore; there was no documented evidence that pressurerelieving equipment was being used. Evidence was seen that care plan reviews had taken place but the care plan had not been updated accordingly. One plan of care was dated 2003. Although the plan of care had been regularly reviewed the risk assessments had not. There were gaps in the recording on a number of charts e.g. turn charts and fluid record charts. There was no evidence that the plan of care had been drawn up with the involvement of the resident/representative.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 8 Due to the above issues it would appear that the health and personal care needs of the residents are not being met. The procedure for the way that the home responds to allegations/incidents of adult abuse must be further developed and staff must be made fully aware of its application and undertake the necessary training. A mechanical hoist was found left on the corridor, a mattress was propped up against the wall on the corridor, which the nurse said had been there since the previous day and a lounge chair was stored in the residents bathroom. These are a potential trip hazard and the inspector requested that they be removed immediately. During a tour of Debdale House 1 of the residents told the inspector that he had not had his breakfast until after 11am that morning despite ringing his buzzer 5 times for assistance. His named nurse confirmed this to be true. She said that this had happened because there was not enough staff. This was discussed with the deputy manager at the time of inspection. The same gentleman was found to be wearing a stained and dirty pyjama top and no pyjama bottoms. The named nurse informed the inspector these clothes had been put back on him because he had no clothes of his own. The resident did have his own pyjamas but they had not been laundered. The inspector had to request that the named nurse send his clothes for immediate washing and request that clean clothes be given to him. This does not promote the dignity of residents. In addition a carer was seen knelt on the floor in the lounge feeding a resident a yogurt. This behaviour does not promote the dignity of residents. Staff spoken to said that they were not receiving supervision. All staff must be appropriately supervised. It is recommended that staff receive formal supervision 6 times a year. Providing staff with the necessary training and making sure that the staff maintain those skills through up-dated and refresher training is important to make sure that the residents needs are being met correctly. All staff must undertake the necessary training and have an individual staff training and development plan. Also evidence must be provided that all staff are appropriately supervised. The homes maintenance man identified a serious concern to the inspector. He told the inspector that the staff on Debdbale House continually wedge open the fire doors and are silencing the alarm on the unit so that the main control panel does not display where the alarm has been activated. He said that he has raised the issue with the staff on numerous occasions but they fail to comply with the correct procedures. The health and safety of residents and staff must be maintained at all times. An action plan must be submitted to Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 9 CSCI detailing how the above issue has been actioned and safety is maintained. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Designated intermediate care facilities are available. EVIDENCE: Since the last inspection the home has registered 12 intermediate care beds on Debdale House.The beds are only to be used for people over the age of 55 being discharged from Central Manchester PCT Acute Trust. These beds are specifically funded by the PCT for intensive, specialised rehabilitation direct from hospital prior to discharge into the community. Designated accommodation is avalable, which includes the appropriate equipment and therapy staff. Policies relating to the new provision and admission/discharge policies have been implemented and a revised Statement of Purpose and Service User’s Guide has also been implemented. The nurses and care staff are currently receiving training in the techniques for rehabilitation.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 12 As already identified in this report one resident, receiving intermediate care, complained to the inspector that he had not had his breakfast until after 11am despite ringing his buzzer for assistance. The nurse confirmed this to be true and told the inspector that this regularly happened because the intermediate care residents were very dependent and that the home was not providing enough staff to meet their care needs and staff were refusing to work with those residents. The deputy manger said that she would discuss the issue with the manager on his return from annual leave. Evidence must be provided that suitably qualified staff are provided in such numbers that are appropriate to meet the health and welfare of the residents assessed needs. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The health and personal care of the residents were not being met. The shortfalls have a potential to place residents at risk. EVIDENCE: A random sample of care files were inspected on Debdale House. A number of shortfalls were identified in the files inspected, some of which are detailed below: • • Evidence could not be provided that all of the care plans had been drawn up, where possible, with the involvement of the resident or their representative. Although the plans of care had been reviewed on a monthly basis a number of risk assessments had not been reviewed since 10/5/05. On 2 care files the ‘review of use of restraint’ form and not been fully completed. Evidence was seen that the care plans had been reviewed monthly but they had not been update to reflect the review. An example is that a care plan was dated 2003 and stated that a slide sheet was required yet the reviews had consistently documented that a hoist was required.
DS0000021678.V285357.R01.S.doc Version 5.1 Page 14 • Gorton Parks Nursing Home • • • • • • The care plans contained vague statements, for example “staff to assist during meals” and “assistance to sit up in bed”. One plan of care clearly documented that “3 hourly turns” were required. No evidence could be found to support that this care had been given. One turn chart evidenced that the resident was sat up at 19.00 on the 26/2/06 and remained in that position until 14.00 on the 27/2/06. Large gaps were found in the recording on another turn chart and also on a fluid balance chart. One care plan evidenced that the Waterlow score was 23 (very high risk). The nurse told the inspector that a pressure-relieving mattress was in place. No documented evidence could be found to support this. A daily progress record of care had been kept, however the standard of documentation was found to be variable. These records must include more detail to accurately reflect the nursing care provided over a 24hour period. The recommendation that the residents’ individual file contain an up to date photograph for easy identification had not been met. A number of concerns were identified in relation to medication: • The file contained a photograph of the resident for easy identification however in some cases the wrong room number was documented. • On examination of the Medicine Administration Record (MAR) sheets it was noted that some prescribed medication e.g. Creams and dressings etc had not been signed for. • Three bottles of Clomethiazole, for the same resident, was found in the drug fridge dated December 2005, January and February 2006. On further investigation it was discovered that the drug had been discontinued. • One resident had 2 opened bottles of Risperdal liquid in the drug trolley. Both of these bottles contained a statement “do not use after 17/12/05”. The nurse in charge confirmed that these 2 bottles of medication were currently in use. • One resident had a half full bottle of Co-Beneldopa dated January 2006 that was currently in use and a full bottle of the same medication dated February 2006 in the store cupboard. According to the MAR sheet the drug had been given as prescribed. This indicates that is possible that medication may not be being administered correctly. • There was a great deal of stock medication dating back a number of months. One was dated 27/6/05. No explanation could be offered for the reason for such a build up. Again this indicates that is possible that medication may not be being administered correctly. • Medication had been signed for on receipt, although not in the appropriate place, however medication, which remained from the previous months, was not taken in to account. In order to have a full audit trail for medication it is essential that the medication retained by
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 15 • the home for later use is included in the stock balance. Without this information it is not possible for an audit trail to be maintained and the home are unable to evidence that medication is administered as prescribed. Initially the nurse in charge was unable to locate the daily fridge temperature recordings and appeared unaware of its importance. However, she did eventually find it and it had not been recorded for 3 days. The manager said that the privacy and dignity of residents was promoted. Staff spoken to confirmed this. However, as already identified in this report 1 resident was observed to be wearing dirty, stained clothing and no pyjama bottoms. In addition, a member of care staff was seen feeding a resident in the lounge, while kneeling on the floor next to her. These incidents do not promote the dignity of the residents. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14 The home supports residents to maintain contact with family and friends and encourages residents to make their own choices. EVIDENCE: The home has an open visitors policy where people can visit residents at any reasonable time. Residents can see visitors in privacy or in quiet communal areas. Staff and resident spoken to confirmed this. No restrictions are placed on visitors unless requested by the resident or agreed through the care management and risk assessment process. From observations of the inspectors and staff spoken to it appeared that residents were able to exercise choice and control with regard to their day-today lives. Several of the bedrooms had been personalised with residents belongings brought in from home. The remaining core standards were assessed during the previous inspection. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home does not have the necessary systems, procedures or practices in place to safeguard residents from abuse. EVIDENCE: The home had a complaint procedure, which was included in the Service User’s Guide, and every resident had been given a copy. The manager maintained a file containing details of the complaints received, and a copy of the conclusion letter sent to the complainant. The file did not contain detailed evidence of any investigations undertaken. The deputy manager showed the inspector the home’s corporate policy, dated September 2003, relevant to vulnerable adult protection. This policy did not accurately reflect the Department of Health ‘No Secrets’ guidance as it stated that the manager would investigate the allegation and the resident would be interviewed. The homes’ own policies must be in line with the multi-agency policy and the Department of Health (DOH) guidance, “No Secrets.” The deputy manager had a copy of the Manchester and Cheshire Multi-Agency Adult Protection Procedures. However, the home does support residents who are placed by different local authorities and they did not have the necessary contact details for making adult protection referrals. These contact numbers must be easily accessible at all times Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 18 The inspector was informed that each unit had a copy of the Manchester MultiAgency Adult Protection Procedures and a Whistle Blowing policy. However, the unit was unable to produce both documents. The staff spoken to said that they had not received any training relating to the Protection of Vulnerable Adults. In order to protect the residents living at the home all staff must receive Protection of Vulnerable Adults Training, which includes the actions to be taken in the event of an allegation of abuse. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgements were made. EVIDENCE: These standards were assessed during the previous inspection. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30 The home was unable to evidence that its staff had the required training to meet resident’s support needs. EVIDENCE: The deputy manager demonstrated that the home are making every effort to meet the National Minimum Standard that 50 of care staff are trained to NVQ Level 2. The home employs 53 care staff, 15 members of staff have successfully completed NVQ level 2 and 7 members of staff were currently undertaking the study and 1 member of staff had successfully completed NVQ level 3. The deputy manager was in the process of developing a computerised training matrix for all staff. Looking at the matrix, evidence could not be provided that staff had undertaken the necessary mandatory (including refresher) training and staff did not have an individual staff training and development plan. From September 2006 a new compulsory Induction Module programme is being introduced by Skills for Care (formerly TOPSS). BUPA have produced a Staff Induction programme that, it says, incorporates Skills for Care Induction Standards. It was found that the induction modules are in fact the old TOPSS modules and is not the compulsory Induction programme introduced by Skills for Care. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 21 The home must develop an induction programme based on the Skills for Care Common Induction Standards within the timescales stated. A copy of this must be provided to the CSCI. The remaining core standards were assessed during the previous inspection. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36 & 38 The health and safety of residents and staff is not being promoted or protected. EVIDENCE: The manager took up post at the home in August 2005. An application for his registration was received on 16th December 2005. An interview date has been set. The home has a clear and transparent system for managing and recording the residents’ personal finances. Written records of all transactions were maintained and receipts were available for inspection. As already referenced in this report some areas of concerns regarding the health and safety of staff and residents have been identified.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 23 Various pieces of equipment were found to be stored in a corridor and a bathroom. These are potential trip hazards and all equipment must be appropriately and safely stored. The homes maintenance man identified a serious concern to the inspector. He told the inspector that the staff on Debdbale House continually wedge open the fire doors and are silencing the alarm on the unit so that the main control panel does not display where the alarm has been activated. He said that he has raised the issue with the staff on numerous occasions but they fail to comply with the correct procedures. This seriously compromises the safety of residents and staff. The health and safety of residents and staff must be maintained at all times. An action plan must be submitted to CSCI detailing how the above issue has been actioned and safety is maintained. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 2 X 1 Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP6 Regulation 18 Requirement The manager must conduct a review of the dependency levels of the residents receiving intermediate care in order to ensure that the home is providing suitably qualified staff in such numbers that are appropriate to meet the health and welfare of the residents assessed needs. This must be submitted to CSCI within the timescales set. 1. The individual plan of care must set out in detail the action staff must take to ensure that all aspects of residents health, personal and social care needs are met. (The previous timescale of 1/8/05 had not been met) 2. The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident whenever possible and/or their representative.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 26 Timescale for action 31/03/06 2. OP7 13, 15 & 17 Sch 3 31/03/06 3. An accurate record must be kept of any nursing provided to the residents including a record of his/her condition and any treatment. 4. Residents care plans must be written with sufficient and accurate detail to provide clear guidance to staff of the actions to be taken to meet the residents health and welfare needs. 5. The risk assessments must be regularly reviewed. 3. OP8 17 Sch 4 The manager must ensure that accurate and updated records of fluids/food intake are recorded to ensure that adequate hydration and nutrition is maintained. (The previous timescale of 1/8/05 had not been met) The responsible individual must make arrangements for the recording, handling and safe administration of medicines which are detailed below: 1. The ordering procedures for medication must be reviewed so that safe levels of medication are in stock. 2. All medication in the home must be within its expiry date. 3. All prescribed medication must be singed for. 4. Daily temperature recordings must be maintained for the drug fridge. 31/03/06 4. OP9 13 31/03/06 Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 27 An action plan must be submitted to CSCI detailing how the above requirements have been actioned within the timescales set. 5. OP10 12 The responsible individual must make suitable arrangement to ensure that the home is conducted in a manner that respects the dignity of residents. 1. The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. 2. The homes Adult Protection policy and procedure must accurately reflect the Departments of Health ‘No Secrets’ guidance. 3. Evidence must be provided that all staff have received Protection of Vulnerable Adult Training, which includes the actions to be taken in the event of an allegation of abuse. 4. The Whistle Blowing policy must be easily accessible at all times. 1. All staff must undertake the necessary mandatory (including refresher) training and have an individual staff training and development plan. (Previous timescale of 1/8/05 had not been met) 2. The home must develop an induction programme based on the Skills for Care Common Induction Standards within the timescales stated.
Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 28 02/03/06 6. OP18 13 01/04/06 7. OP30 18 07/05/06 8. 9. 10. OP31 OP36 OP38 9 18 12 & 13 A copy of this must be provided to the CSCI. The manager must be registered with CSCI. The responsible individual must ensure that all staff are appropriately supervised. To ensure the health and safety of residents and staff are protected at al times the responsible individual must ensure: 1. Fire doors must not be wedged open. 2. The fire alarm on the units must not be silenced as this disables the display that identifies where the alarm has been activated. An action plan must be submitted to CSCI detailing how the above issue has been actioned and safety is maintained. 3. Equipment must not be stored on corridors or in residents’ bathrooms. 18/04/06 01/04/06 02/03/06 Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP16 Good Practice Recommendations It is recommended that the residents’ individual file contain an up to date photograph for easy identification. It is recommended that the complaint file contain details of any investigation undertaken which includes details of any staff statements or interviews. Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gorton Parks Nursing Home DS0000021678.V285357.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
